Scar Revision

Created on 25th September 2008

Greg Williams, consultant plastic surgeon at London Plastic Surgery Associates, talks us through the options in scar revision treatment

When the skin is cut, either accidentally or during a surgical procedure, scarring occurs. The quality of scars can vary greatly and is influenced not only by the time taken for the wound to heal but also by age, ethnicity, and location on the body. In Caucasians scars tend to be pale while on darker skins scars tend to be hyperpigmented.

Abnormal scars can be categorized as stretched, hypertrophic or keloid.

Stretched scars
Stretched scars are widened and often occur on the back or over the shoulders, knees and elbows. Scar revision in these areas is often disappointing, as the scars tend to regain their original appearance over time. However, stretched scars in other parts of the body can usually be significantly improved.

Hypertrophic scars
These are raised and lumpy but remain within the area of the cut or incision. Often they are itchy and in pale-skinned individuals they tend to be pink or red. The natural progression of these types of scars is for them to soften and flatten over time but this process can be hastened by steroid injections.

The steroids have no effect on the rest of the body but may cause the scars to become atrophic or papery in the long term and may cause thread veins to appear on the surface of the scar. Plastic surgeons will often advise patients to wait until the hypertrophy has settled before considering scar revision and this may take twelve to eighteen months and sometimes longer.

Keloid scars
These scars are similar to hypertrophic scars but can grow outside of the original area of trauma and are more common on the epaulette region of the shoulder, the sternal area of the chest and the earlobes. They are more common in Afro-Caribbean individuals and in certain Oriental races but some people are prone to them for unknown reasons and a tendency to keloid scar formation can run in families. Operating on keloid scars can be unpredictable and the resulting scar can end up bigger than the original one. Intra-operative steroid injections into the scar revision wound and post-operative low dose radiotherapy may reduce the recurrence rate of keloid scars.

Treatment options
When scars cross joints they may cause tight bands or contractures which restrict movement. This can be improved by using local flaps of healthy skin to break up the tight bands. With extensive scarring as can occur in burn injuries, improvement can sometimes be achieved by using traditional skin grafts or modern skin replacement technologies.

Even ‘normal', i.e. thin and flat, scars can sometimes be improved by changing their direction so that they come to lie in natural skin creases or where there is less tension in the skin. Revising a scar and improving the healing time or introducing early massage and silicone gel pads can often produce a far better appearance. Some scars can also be hidden using cosmetic camouflage techniques that can be taught by a beautician.

A skilled plastic surgeon can improve many scars by surgical revision but there is no such thing as invisible healing. Having realistic expectations is essential. At LPSA the pre-operative consultation is always with the surgeon who will be performing the surgery and who will take the time to ensure that you have a thorough understanding of the procedure and the likely outcome. CSMUK